DECISIONAL AND PROGNOSTIC IMPACT OF DIAGNOSTIC URETEROSCOPY IN HIGH-RISK UPPER TRACT UROTHELIAL CARCINOMA: A MULTI-INSTITUTIONAL COLLABORATIVE ANALYSIS (ROBUUST COLLABORATIVE GROUP)

INTRODUCTION AND OBJECTIVE: Current guidelines strongly recommend against the use of diagnostic ureteroscopy (URS) in the diagnostic pathway for upper tract urothelial carcinoma (UTUC). We aimed at analysing the decision-making and prognostic role of diagnostic URS in high-risk patients undergoing radical nephroureterectomy (RNU). METHODS: Data were retrieved from the ROBUUST (ROBotic surgery for Upper tract Urothelial cancer STudy) multicenter international (2015-2022) dataset. A retrospective comparative analysis was conducted to evaluate

INTRODUCTION AND OBJECTIVE: Current guidelines strongly recommend against the use of diagnostic ureteroscopy (URS) in the diagnostic pathway for upper tract urothelial carcinoma (UTUC).We aimed at analysing the decision-making and prognostic role of diagnostic URS in high-risk patients undergoing radical nephroureterectomy (RNU).
METHODS: Data were retrieved from the ROBUUST (ROBotic surgery for Upper tract Urothelial cancer STudy) multicenter international (2015-2022) dataset.A retrospective comparative analysis was conducted to evaluate the characteristics of high-risk patients who either underwent pre-operative URS and biopsy before RNU or did not, and its impact on surgical and oncological outcomes.Survival analysis included recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS) and overall survival (OS).Cox proportional hazard model was used to evaluate significant predictors of time-to-event outcomes.Logistic regression analysis was performed to evaluate differences between patients receiving URS and, based on their URS status, to determine their likelihood of receiving kidney-sparing surgery and a specific surgical approach.
RESULTS: Overall, 1,912 patients were included, 1,035 undergoing URS and biopsy and 877 not receiving endoscopic diagnosis prior to RNU.A mean follow-up of 28.9 months was obtained.Patients undergoing pre-operative URS were more likely female (OR 0.67, 95% CI 0.51-0.87),with smaller (OR 0.31, 95% CI 0.22-0.43),and organconfined tumors (OR 0.47, 95% CI 0.34-0.64),compared to patients not receiving URS.Robot-assisted RNU was the most common procedure (55.1%), in both subgroups.At survival analysis, CSS was significantly higher for patients undergoing URS (37 months vs 20 months, p<.001).However, the two cohorts were comparable in terms of RFS (p[.6), MFS (p[.3) and OS (p[.07).In Cox regression analysis, URS was not a significant predictor of worse oncological outcomes for each time-to-event outcome.Likewise, in logistic regression analysis, pre-operative ureteroscopy was not a significant predictor of a certain surgical approach or technique.
CONCLUSIONS: Diagnostic ureteroscopy is performed mostly in patients with smaller localized tumors.Patients undergoing ureteroscopy had a longer CSS, even though statistical significance was lost at Cox analysis.Surgical strategy is likely determined more by tumour pathology features than by ureteroscopy findings.

MP38-19 REAL-WORLD OUTCOMES OF ADJUVANT IMMUNOTHERAPY CANDIDATES WITH UPPER TRACT UROTHELIAL CARCINOMA: RESULTS OF A MULTICENTER COHORT STUDY
Hirokazu Kagawa*, Fumihiko Urabe, Kosuke Iwatani, Yu Imai, Kojiro Tashiro, Shunsuke Tsuzuki, Akira Furuta, Takahiro Kimura, Tokyo, Japan INTRODUCTION AND OBJECTIVE: Recent clinical trial (CheckMate 274 trial) has reported improved disease-free survival rates of patients with stage pT3e4/ypT2e4 or (y)pNþ upper tract urothelial carcinoma (UTUC) on adjuvant nivolumab therapy.However, the appropriateness of the patient selection criteria used in clinical practice remains uncertain.
METHODS: We retrospectively analyzed 895 patients who underwent nephroureterectomy to treat UTUC.The patients were divided into two groups: grade pT3e4 and/or pNþ without neoadjuvant chemotherapy (NAC) or grade ypT2e4 and/or ypNþ on NAC (adjuvant immunotherapy candidates) and others (not candidates for adjuvant immunotherapy).Kaplan-Meier curves were drawn to assess the oncological outcomes, i.e., recurrence-free survival (RFS), cancerspecific survival (CSS), and overall survival (OS).Cox proportional hazards models were used to identify significant prognostic factors for oncological outcomes.
RESULTS: In total, 44.8% of patients were candidates for adjuvant immunotherapy.During follow-up, 232 (25.9%) patients developed metastases; there were 145 (16.2%) cases of cancerspecific mortality and 189 (21.1%) patients died of any cause.The 3year RFS, CSS, and OS rates were 72.2%, 83.1%, and 79.0%, respectively.The Kaplan-Meier curves revealed significantly inferior RFS, CSS, and OS among candidates for adjuvant immunotherapy (p<0.01,p<0.01, and p<0.01, respectively) (Figure 1aec).In contrast, the RFS, CSS, and OS did not differ significantly between candidates for adjuvant immunotherapy on NAC and not on NAC (p[0.75,p[0.67,and p[0.93,respectively) (Figure 1aec).Similar trends were observed in those who were not candidates for adjuvant immunotherapy (p[0.90, p[0.46, and p[0.69, respectively) (Figure 1aec).Multivariate analysis revealed that pathological T (pT3e4 or ypT2e4) and N (pNþ or ypNþ) and lymphovascular invasion (LVI) status were independent risk factors for poor RFS, CSS, and OS.CONCLUSIONS: The adjuvant immunotherapy candidate criteria can be used to stratify UTUC patients post-nephroureterectomy.In addition to pathological T and N status, LVI was a significant predictor of survival, and may thus play a pivotal role in the selection of patients eligible for adjuvant immunotherapy.